IT in RadiographyChapter 4

OVERVIEW

● Definition of HIS● Importance of HIS● Modules of HIS

DEFINITION

● A hospital information system (HIS) is a comprehensive, integrated information system designed to manage the administrative, financial and clinical aspects of a hospital.

● This encompasses paper-based information processing as well as data processing machines.

DEFINITION

A hospital information system:● Is an important quality factor, but an enormous

cost factor as well. ● Is becoming a productivity factor● Should offer a holistic view of the patient and of

the hospital.

IMPORTANCE OF HIS

The integrated processing of information is important because

● all groups of people and all areas of a hospital depend on its quality,

● the amount of information processing in hospitals is considerable, and

● health care professionals frequently work with the same data

MODULES OF HIS

● Patient care● Supply and disposal management, scheduling

and resource allocation● Hospital administration● Hospital management● Research and education

PATIENT CARE

Patient Care aspect can be categorized as follows:– Patient admission

– Decision making, planning and organization of patient treatment

– Order entry

– Execution of diacnostic, therapeutic and nursing procedures

– Coding of diagnoses and procedures

– Patient discharge

Patient Admission

● Patient admission aims at recording and distributing the patient demographics and insurance data as well as medical and nursing data of the patient history

● In addition, each patient must becorrectly identified, and a unique patient and case identifier must be assigned

Patient Admission

● Appointment scheduling● Patient identification and checking for recurrent● Administrative admission● Medical admission● Nursing admission● Visitor and information service

Patient Admission

● Appointment scheduling– The hospital must be able to schedule an

appointment for a patient's visit. In addition, unplanned patient admissions must be possible (e.g., in case of emergencies)

Patient Admission

● Appointment scheduling● Patient identification and checking for

recurrent● Administrative admission● Medical admission● Nursing admission● Visitor and information service

Patient Admission

● Patient identification and checking for recurrent:– A unique registration number (R/N) must be

assigned to each patient:

– This R/N should be valid and unchangeable

– The R/N is the main precondition for a patient-oriented combination of all information arising during previous, recent as well as future hospitalizations

Patient Admission

● Patient identification and checking for recurrent:– If the patient has already been in the hospital, she

or he must be identified as recurrent, and previously documented information must be made available (such as previous diagnoses and therapies).

– In addition, the hospital must be able to distinguish different cases or hospital stays of a patient.

Patient Admission

● Appointment scheduling● Patient identification and checking for recurrent● Administrative admission● Medical admission● Nursing admission● Visitor and information service

Patient Admission

● Administrative admission:– Administrative data form the backbone of

information processing

– Administrative admission starts following patient identification. It creates a so-called case.

– In case of inpatient treatment, a case summarizes the hospital stay from patient admission until discharge

Patient Admission

● Administrative admission:– Each case is uniquely identified by its case number.

Important administrative data such as insurance data, details about special services, patient's relatives, admitting physician, and transfer diagnoses must be recorded

– In case of changes, patient data must be maintained and communicated. If the admitting physician has communicated relevant information (e.g., previous laboratory findings), this information must be communicated to the responsible physician in the hospital

Patient Admission

● Administrative admission:– Administrative admission is usually done either in a

central patient admission area or directly on the ward

– Even in emergencies patient admission is necessary. At least patient identification and checking for recurrent has to be performed in order to assign a proper R/N and case number.

– If the patient is unconscious and does not bear an identity card, only a dummy name may be recorded to provide R/N and case number.

Patient Admission

● Appointment scheduling● Patient identification and checking for recurrent● Administrative admission● Medical admission● Nursing admission● Visitor and information service

Patient Admission

● Medical admission:– The responsible physician will carry out the medical

admission.

– This typically comprises the patient history (disease history, systems review, social history, past medical history, family history, medication).

– Some of this information may be collected from documents of the referring physician and is taken to the hospital by the patient himself.

– Medical admission is usually done on the ward

Patient Admission

● Medical admission:– As a result of medical admission the admission

diagnosis has to be stated and to be coded

– The basic patient history data have to be made available for other hospital functions.

– For the patient history there may also be department-specific, (semi-) standardized data entry forms available

– The collected information should be available during the whole stay

Patient Admission

● Appointment scheduling● Patient identification and checking for recurrent● Administrative admission● Medical admission● Nursing admission● Visitor and information service

Patient Admission

● Nursing admission:– The responsible nurse will proceed with the nursing

admission.

– This typically comprises the introduction of the patient to the ward and the nursing history.

– Nursing admission is usually done at the ward, and administrative data and the reason of hospitalization are already at her or his disposal

Patient Admission

● Nursing admission:– For the nursing history there may be computer-

based or department-specific, (semi-) standardized data entry forms available.

– These may contain information about the current diagnosis and therapy, orientation, communication ability, social contacts, nutrition, mobility, personal hygiene, and vital signs

– The collected information should be available during the whole stay

Patient Admission

● Appointment scheduling● Patient identification and checking for recurrent● Administrative admission● Medical admission● Nursing admission● Visitor and information service

Patient Admission

● Visitor and information services:– The hospital management must always have an

overview of the recent bed occupation, i.e., about the patients’ staying at the hospital.

– This is, for example, important for the receptionist at the information desk, who must be able to inform relatives and visitors correctly, and also for some general hospital management statistics